Provider Demographics
NPI:1245215268
Name:REDCO GROUP, LLC
Entity Type:Organization
Organization Name:REDCO GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SOHOSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-628-5215
Mailing Address - Street 1:16 S CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3001
Mailing Address - Country:US
Mailing Address - Phone:570-628-5234
Mailing Address - Fax:570-628-9051
Practice Address - Street 1:16 S CENTRE ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3001
Practice Address - Country:US
Practice Address - Phone:570-628-5234
Practice Address - Fax:570-628-9051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2020-10-08
Deactivation Date:2018-04-30
Deactivation Code:
Reactivation Date:2020-10-07
Provider Licenses
StateLicense IDTaxonomies
PA209010261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000017170155Medicaid